Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer
Authors: R. Scott Braithwaite
Journal: Annals of Internal Medicine (2010)

Letters20 April 2010Comments and Response on the USPSTF Recommendation on Screening for Breast CancerFREER. Scott Braithwaite, MD, MSR. Scott Braithwaite, MD, MSFrom New York University School of Medicine, New York, NY 10016.Search for more papers by this authorAuthor, Article, and Disclosure Informationhttps://doi.org/10.7326/0003-4819-152-8-201004200-00201 SectionsAboutVisual AbstractPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissions ShareFacebookTwitterLinkedInRedditEmail TO THE EDITOR:The USPSTF update of screening mammography recommendations (1) created controversy because many people feared it was motivated by cost containment rather than scientific evidence (2). However, neither the Task Force nor the underlying studies considered costs or cost-effectiveness (3, 4). It is tempting to attribute this misunderstanding to unfortunate timing: The USPSTF, a government-appointed body, recommended against routine mammography at a time when the government's role in controlling health spending was being widely debated. However, the true culprit behind misinterpretation may be more subtle. The metric underlying the USPSTF decisions, number needed to screen (NNS), obscures the rationale of subsequent decisions.A decision based on NNS has many potential rationales. An unfavorably high NNS can argue against screening, because harms exceed benefits; the risk–benefit ratio is “too close to call” (either from a population or from an individual perspective); or benefits exceed harms, but not by enough to justify expenditures. The first 2 rationales do not consider cost, whereas the third rationale does. Because NNS-based decisions can be attributed to many rationales, NNS invites misinterpretation. Furthermore, no NNS threshold is universally favorable or unfavorable. An NNS of 10 (usually favorable) may be unfavorable if the harms and costs of screening are substantial but the benefits are slight. Conversely, an NNS of 10 000 (usually unfavorable) may be favorable if the harms and costs of screening are minimal but the benefits are substantial.The USPSTF revised recommendations for women aged 39 to 49 years because the NNS of mammography increased to 1904 (1), a number that is usually unfavorable. The likely rationale was that risk–benefit ratio was too close to call, particularly on an individual patient basis. For women who attach great value to avoiding consequences of false-positive results (for example, biopsies and their potential complications or anxiety), harms may exceed benefits. However, for women who attach little value to avoiding these consequences, benefits may exceed harms. Accordingly, the USPSTF advised neither in favor of routine mammography (grades A or B) nor against it (grade D), but rather advised individualized decision making (grade C). However, because the USPSTF's rationale was implicit, it was misinterpreted. Many assumed the USPSTF was using NNS as a backdoor to rationing.When expert groups invoke NNS to recommend against routine screening, they should specify their rationale, especially given current sensitivities about rationing. Misattributing a recommendation to cost rather than risk–benefit ratio wastes a teachable moment on how screening can cause harms and may erode the toehold of evidence-based medicine in the U.S. health care system.R. Scott Braithwaite, MD, MSNew York University School of MedicineNew York, NY 10016References1. U.S. Preventive Services Task Force. Screening for breast cancer: U.S. Preventive Services Task Force recommendation statement. Ann Intern Med. 2009;151:716-26, W-236. [PMID: 19920272] MedlineGoogle Scholar2. A breast cancer preview: the mammogram decision is a sign of cost control to come. Wall Street Journal. 19 November 2009. Accessed at online.wsj.com/article/SB10001424052748704204304574543721253688720.html on 3 February 2010. Google Scholar3. Nelson HD, Tyne K, Naik A, Bougatsos C, Chan BK, Humphrey L; U.S. Preventive Services Task Force. Screening for breast cancer: an update for the U.S. Preventive Services Task Force. Ann Intern Med. 2009;151:727-37, W237-42. [PMID: 19920273] LinkGoogle Scholar4. Mandelblatt JS, Cronin KA, Bailey S, Berry DA, de Koning HJ, Draisma G, et al; Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network. Effects of mammography screening under different screening schedules: model estimates of potential benefits and harms. Ann Intern Med. 2009;151:738-47. [PMID: 19920274] LinkGoogle Scholar Comments0 CommentsSign In to Submit A Comment Author, Article, and Disclosure InformationAuthors: R. Scott Braithwaite, MD, MSAffiliations: From New York University School of Medicine, New York, NY 10016.Disclosures: None disclosed. PreviousarticleNextarticle Advertisement FiguresReferencesRelatedDetailsSee AlsoScreening for Breast Cancer: U.S. Preventive Services Task Force Recommendation StatementU.S. Preventive Services Task Force* Screening for Breast Cancer: An Update for the U.S. Preventive Services Task Force Heidi D. Nelson , Kari Tyne , Arpana Naik , Christina Bougatsos , Benjamin K. Chan , and Linda Humphrey Effects of Mammography Screening Under Different Screening Schedules: Model Estimates of Potential Benefits and Harms Jeanne S. Mandelblatt , Kathleen A. Cronin , Stephanie Bailey , Donald A. Berry , Harry J. de Koning , Gerrit Draisma , Hui Huang , Sandra J. Lee , Mark Munsell , Sylvia K. Plevritis , Peter Ravdin , Clyde B. Schechter , Bronislava Sigal , Michael A. Stoto , Natasha K. Stout , Nicolien T. van Ravesteyn , John Venier , Marvin Zelen , and Eric J. Feuer , for the Breast Cancer Working Group of the Cancer Intervention and Surveillance Modeling Network (CISNET)* When Evidence Collides With Anecdote, Politics, and Emotion: Breast Cancer ScreeningThe EditorsComments and Response on the USPSTF Recommendation on Screening for Breast Cancer Mitchell H. Gail and Catherine Schairer Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Colin B. Begg Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Richard Yoast Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Victoria L. Seewaldt Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Nananda F. Col , Moritz H. Hansen , Baruch Fischhoff , and Steven G. Pauker Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Anita Ho Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Diana Pettiti and Ned Calonge Comments and Response on the USPSTF Recommendation on Screening for Breast Cancer Peter B. Dean Metrics Cited byPersonalizing Age of Cancer Screening Cessation Based on Comorbid Conditions: Model Estimates of Harms and BenefitsIris Lansdorp-Vogelaar, PhD, Roman Gulati, MS, Angela B. Mariotto, PhD, Clyde B. Schechter, MD, MA, Tiago M. de Carvalho, MSc, Amy B. Knudsen, PhD, Nicolien T. van Ravesteyn, PhD, Eveline A.M. Heijnsdijk, PhD, Chester Pabiniak, MSc, Marjolein van Ballegooijen, MD, PhD, Carolyn M. Rutter, PhD, Karen M. Kuntz, ScD, Eric J. Feuer, PhD, Ruth Etzioni, PhD, Harry J. de Koning, MD, PhD, Ann G. Zauber, PhD, and Jeanne S. Mandelblatt, MD, MPHQuality varies across clinical practice guidelines for mammography screening in women aged 40–49 years as assessed by AGREE and AMSTAR instrumentsWhen Evidence Collides With Anecdote, Politics, and Emotion: Breast Cancer ScreeningThe Editors 20 April 2010Volume 152, Issue 8Page: 539-540KeywordsAnxietyBiopsyBreast cancerCancer screeningConflicts of interestDecision makingEvidence based medicineHealth careMammographyNumber needed to screen ePublished: 20 April 2010 Issue Published: 20 April 2010 Copyright & PermissionsCopyright © 2010 by American College of Physicians. All Rights Reserved.PDF downloadLoading ...